What does my
UIM attending
expect on the
Mini-CEX?
Round 1
7/17/13
General Guides
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The Mini-CEX, or observed history and physical
exam, is a board requirement of the ABIM
The attending physician must observe you as you
do portions of the history and physical. Do not ask
the attending to “sign off” because you have
presented the history or physical findings
Your attending will not make overt corrections to
your technique when you are with the patient, but
will give you feedback afterward. We do not want
to undermine your relationship with the patient
Plan the Mini-CEX, tell the attending, then take the
attending in the room to watch – no need to do
this twice. Use Chief Complaint as your guide.
General Guides
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Barbara Bates remains a great reference
All of your histories and physicals will be
tailored to the patient’s chronic issues or chief
complaints (for the rest of your life!)
Get patients into gowns for anything involving
a stethoscope. Nothing causes your UIM
attending more angst than watching you try
to auscultate anything through clothes!
You need your H&P skills for outpatient Internal
Medicine – this is our main procedure
Relative Gain from the History,
PE and labs
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“In 61 patients (76%), the history led to the
final diagnosis. The physical examination led
to the diagnosis in 10 patients (12%), and the
laboratory investigation led to the diagnosis in
9 patients (11%). The internists' confidence in
the correct diagnosis increased from 7.1 on a
scale of 1 to 10 after the history to 8.2 after
the physical examination and 9.3 after the
laboratory investigation.”
West J Med. 1992 February; 156(2): 163–165
Physical Exam remains
important
 "You
know, we often spend so much time
with that entity in the computer — I call it
the 'iPatient,' like your iPad and your
iPhone. And the real patient in the bed is
often left wondering, 'Where is
everybody? What are they doing?' I sense
that we're spending very little time at the
bedside.“
 Abraham Verghese, MD Stanford –
quoted on NPR
Mini-CEX UIM 2013
Item
Date
1.
History of a new
complaint
1.
Medication history
1.
Chronic pain history
(psych)
Focused physical
exam
1.
1.
CV exam
1.
Lung exam
1.
Abdominal exam
1.
Musculoskeletal
exam
1.
Neurological exam
1.
Pelvic exam (GYN)
1.
Knee exam (Ortho)
1.
Shoulder exam
(Ortho)
1.
Hip exam (Ortho)
1.
Teach-back
1.
Shared decisionmaking
Supervisor
History of a new complaint
 Remember
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“COLDERR AS” for pain:
“O” Onset
“L” Location
“D” Duration
“C” Character/Quality
“S” Severity
“R” Radiation
“E” Exacerbating/”R” Relieving
“A” Associated symptoms
Medication History
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Physicians should be doing “Medication Reconciliation”
Medication Reconciliation
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Create the most accurate list possible of all medications
a patient is taking
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Compare that list against the physician’s admission,
transfer, and/or discharge orders
 GOAL: provide correct medications to patient at all
transition points
(Amy Thompson, PharmD)
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Drug Name
Dosage
Frequency
Route
Medication History
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Emphasis at Hospital Discharge
Comparing what patient is taking at home to
the Epic list and hospital discharge list –
identifying high risk medications
Using outside resources
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Call pharmacies/family
Home Health orders
Creating accurate list in Epic
Using Teach-Back to clarify patient instructions
Chronic Pain History
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History of the pain including diagnostic studies
All medical records obtained including DHEC report
Previous treatments and response/adverse effects – focus on
function
Psychosocial factors and family history – include
compensation/legal factors
UDS
Goals of therapy - functional
Assessment of risks for opioid abuse (DIRE)
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Personal or family history of drug abuse(tobacco use)
Psychological factors: personality disorder, affective disorder, etc.
Reliability: medication misuse, missed appointments
Social support
Efficacy: functional
Documentation in the Problem List
Focused Physical Exam
 Can
you limit the physical to the chief
complaint and/or chronic medical
conditions?
 HTN – CV exam, measure BP manually
 Cardiac history – CV exam, lungs
 Headache – neuro exam critical
 Etc.
Teach-Back
[Elisha Brownfield]
stolen from:
A program created by
the Minnesota Health Literacy Partnership
The problem with communication is
the illusion that it has occurred.
>-- George Bernard Shaw
Teach-Back . . .
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Asking patients to repeat in their own words what
they need to know or do, in a non-shaming way.
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NOT a test of the patient, but of how well you
explained a concept.
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A chance to check for understanding and, if
necessary, re-teach the information.
Teach-Back . . . Why?
Teach-Back is supported by research!
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“Asking that patients recall and restate what
they have been told” is one of the 11 top
patient safety practices based on the strength
of scientific evidence.”
AHRQ, 2001 Report, Making Health Care Safer
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“Physicians’ application of interactive
communication to assess recall or
comprehension was associated with better
glycemic control for diabetic patients.”
Schillinger, Arch Intern Med/Vo640 l 163, Jan 13, 2003, “Closing the Loop”
Teach-Back . . . How?
Ask patients to demonstrate understanding
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“What will you tell your spouse about your condition?”
“I want to be sure I explained everything clearly, so can you
please explain it back to me so I can be sure I did.”
“Show me what you would do.”
Chunk and check
Summarize and check for
understanding throughout,
don’t wait until the end.
Do NOT ask . . .
 “Do you understand?”
Additional Points. . .
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Slow down.
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Use a caring tone of voice and attitude.
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Use plain language.
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Break it down into short statements.
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Focus on the 2 or 3 most important concepts.
Shared decision-making
 What
is shared decision making?
 Shared decision making is an approach
where clinicians and patients make
decisions together using the best
available evidence. (Elwyn et al, BMJ,
2010
Shared Decision-making for:
 undergo
a screening or diagnostic test
 undergo a medical or surgical procedure
 participate in a self-management
education program or psychological
intervention
 take medication
 attempt a lifestyle change.
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www.kingsfund.org.uk
Elements from the Clinician
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developing empathy and trust
negotiated agenda-setting and prioritizing
information sharing
re-attribution (if appropriate)
communicating and managing risk
supporting deliberation
summarizing and making the decision
documenting the decision
How do I do that?
 Negotiated
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agenda setting/prioritizing
‘What do you want to talk about in our time
together today?’
‘What questions do you have?’
What concerns do you have?’
‘What is it that I need to know so that I can
help you reach the best decision?’
‘There are other things that I’d like to discuss
– is that OK?’
How do I do that?
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Information sharing
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‘What do you understand about your
condition?’
‘What do you understand about what is
happening in your body when you get your
symptoms?’
‘What have you been told about your
condition?’
‘What have you been told is happening in your
body when you get your symptoms?’
‘What concerns or worries do you have about
your condition?’
How do I do that?
 Re-attribution
 ‘Many
people who have angina think like
that. The evidence is that angina isn’t
actually a heart attack. Now I have
shared that thought with you, what does
that mean for you?’